A.S. Rudoy
The review summarizes the key points and main evidence of the updated modern recommendations of the European Society of Cardiology in 2019, which influenced the principles of management and treatment of patients with chronic coronary syndromes. The new concept and recognition of the importance of the multifactorial causes of angina pectoris and myocardial ischemia represents an important evolution in understanding the pathogenesis and treatment of coronary artery disease.
keywords: guidelines, chronic coronary syndromes, angina pectoris, myocardial ischaemia, stable coronary artery disease, risk factors, anti-ischaemic drugs, antiplatelet agents, oral anticoagulants, coronary revascularization

for references: A.S. Rudoy. Chronic coronary syndromes: a review of the recommendations of the ESC-2019. Neotlozhnaya kardiologiya i kardioovaskulyarnye riski [Emergency cardiology and cardiovascular risks], 2019, vol. 3, no. 2, pp. 636–652

1. Knuuti, J., Wijns, W., Saraste, A., Capodanno, D., Barbato, E., Funck-Brentano, C., Prescott E., Storey R.F., Deaton C., Cuisset T., Agewall S., Dickstein K., Edvardsen T., Escaned J., Gersh B.J., Svitil P., Gilard M., Hasdai D., Hatala R., Mahfoud F., Masip J., Muneretto C., Valgimigli M., Achenbach S., Bax J.J. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes Eur Heart J, 2019, vol. 31, pii: ehz425. doi: 10.1093/eurheartj/ehz425.
2. Juarez-Orozco L.E., Saraste A., Capodanno D., Prescott E., Ballo H., Bax J.J., Wijns W., Knuuti J. Impact of a decreasing pre-test probability on the performance of diagnostic tests for coronary artery disease. Eur Heart J Cardiovasc Imaging, 2019, vol. 20, no. 11, pp. 1198–1207. doi: 10.1093/ehjci/jez054.
3. Reeh J., Therming C.B., Heitmann M., Hojberg S., Sorum C., Bech J., Husum D., Dominguez H., Sehestedt T., Hermann T., Hansen K.W., Simonsen L., Galatius S., Prescott E. Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina. Eur Heart J, 2018, vol. 40, no. 18, pp. 1426–1435. doi: 10.1093/eurheartj/ehy806.
4. Foldyna B., Udelson J.E., Karady J., Banerji D., Lu M.T., Mayrhofer T., Bittner D.O., Meyersohn N.M., Emami H., Genders T.S.S., Fordyce C.B., Ferencik M., Douglas P.S., Hoffmann U. Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond-Forrester for the contemporary era and clinical implications: insights from the PROMISE trial. Eur Heart J Cardiovasc Imaging, 2019, vol. 20, no. 5, pp. 574-581. doi: 10.1093/ehjci/jey182.
5. Reeh J., Therming C.B., Heitmann M., Hojberg S., Sorum C., Bech J., Husum D., Dominguez H., Sehestedt T., Hermann T., Hansen K.W., Simonsen L., Galatius S., Prescott E. Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina. Eur Heart J, 2018, vol. 40, no. 18, pp. 1426–1435. doi: 10.1093/eurheartj/ehy806.
6. Lindholm D., Lindbäck J., Armstrong P.W., Budaj A., Cannon C.P., Granger C.B., Hagström E., Held C., Koenig W., Östlund O., Stewart R.A.H., Soffer J., White H.D., de Winter R.J., Steg P.G., Siegbahn A., Kleber M.E., Dressel A., Grammer T.B., März W., Wallentin L. Biomarker-Based Risk Model to Predict Cardiovascular Mortality in Patients With Stable Coronary Disease. J Am Coll Cardiol, 2017, vol. 70, no. 7, pp. 813–826. doi: 10.1016/j.jacc.2017.06.030.
7. Valgimigli M., Bueno H., Byrne R.A., Collet J.P., Costa F., Jeppsson A., J ni P., Kastrati A., Kolh P., Mauri L., Montalescot G., Neumann F.J., Petricevic M., Roffi M., Steg P.G., Windecker S., Zamorano J.L. Special article 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Rev Esp Cardiol (Engl Ed), 2018, vol. 71, no. 1, pp. 42. doi: 10.1016/j.rec.2017.11.020.
8. Steffel J., Verhamme P., Potpara T.S., Albaladejo P., Antz M., Desteghe L., Haeusler K.G., Oldgren J., Reinecke H., Roldan-Schilling V., Rowell N., Sinnaeve P., Collins R., Camm A.J., Heidbüchel H. The 2018 European Heart Rhythm Association Practical Guide on the use of vitamin К antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J, 2018, vol. 39, no. 16, pp. 1330–1393. doi: 10.1093/eurheartj/ehy136.
9. Xaplanteris P., Fournier S., Pijls N.H.J., Fearon W.F., Barbato E., Tonino P.A.L., Engstrom T., Kaab S., Dambrink J.H., Rioufol G., Toth G.G., Piroth Z., Witt N., Frobert O., Kala P., Linke A., Jagic N., Mates M., Mavromatis K., Samady H., Irimpen A., Oldroyd K., Campo G., Rothenbuhler M., Juni P., de Bruyne B. Five-year outcomes with PCI guided by fractional flow reserve. N Engl J Med, 2018, vol. 379, no. 3, pp. 250–259. doi: 10.1056/NEJMoa1803538.
10. Al-Lamee R., Thompson D., Dehbi H.M., Sen S., Tang K., Davies J., Keeble T., Mielewczik M., Kaprielian R., Malik I.S., Nijjer S.S., Petraco R., Cook C., Ahmad Y., Howard J., Baker C., Sharp A., Gerber R., Talwar S., Assomull R., Mayet J., Wensel R., Collier D., Shun-Shin M., Thom S.A., Davies J.E., Francis D.P. Percutaneous coronary intervention in stable angina (ORBITA): a doubleblind, randomised controlled trial. Lancet, 2018, vol. 391, no. 10115, pp. 31–40. doi: 10.1016/S0140-6736(17)32714-9.
11. Windecker S., Stortecky S., Stefanini G.G., da Costa B.R., Rutjes A.W., Di Nisio M., Silletta M.G., Maione A., Alfonso F., Clemmensen P.M., Collet J.P., Cremer J., Falk V., Filippatos G., Hamm C., Head S., Kappetein A.P., Kastrati A., Knuuti J., Landmesser U., Laufer G., Neumann F.J., Richter D., Schauerte P., Sousa Uva M., Taggart D.P., Torracca L., Valgimigli M., Wijns W., Witkowski A., Kolh P., Juni P. Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis. BMJ, 2014, vol. 23, no. 348, g3859. doi: 10.1093/eurheartj/ehw036.
12. Zimmermann F.M., Omerovic E., Fournier S., Kelbaek H., Johnson N.P., Rothenbuhler M., Xaplanteris P., Abdel-Wahab M., Barbato E., Hofsten D.E., Tonino P.A.L., Boxmade Klerk B.M., Fearon W.F., Kober L., Smits P.C., De Bruyne B., Pijls N.H.J., Juni P., Engstrom T. Fractional flow reserve-guided percutaneous coronary intervention vs. medical therapy for patients with stable coronary lesions: meta-analysis of individual patient data. Eur Heart J, 2019, vol. 40, no. 2, pp. 180–186. doi: 10.1093/eurheartj/ehy812.
13. Knuuti J., Ballo H., Juarez-Orozco L.E., Saraste A., Kolh P., Rutjes A.W.S., Juni P., Windecker S., Bax J.J., Wijns W. The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability. Eur Heart J, 2018, vol. 39, no. 35, pp. 3322–3330. doi: 10.1093/eurheartj/ehy267.
14. Neumann, Franz-Josef, et al. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J, 2018, vol. 40, no. 2, pp. 87–165. doi: 10.1093/eurheartj/ehu278.
15. Giugliano R.P., Cannon C.P., Blazing M.A., Nicolau J.C., Corbalan R., Spinar J., Park J.G., White J.A., Bohula E.A., Braunwald E. IMPROVE-IT (Improved Reduc tion of Outcomes: Vytorin Efficacy International Trial) Investigators. Benefit of adding ezetimibe to statin therapy on cardiovascular outcomes and safety in patients with versus without diabetes mellitus: results from IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial). Circulation, 2018, vol. 137, no. 15, pp. 1571–1582. doi: 10.1161/CIRCULATIONAHA.117.030950.
16. Rosenson R.S., Baker S., Banach M., Borow K.M., Braun L.T., Bruckert E., Brunham L.R., Catapano A.L., Elam M.B., Mancini G.B.J., Moriarty P.M., Morris P.B., Muntner P., Ray K.K., Stroes E.S., Taylor B.A., Taylor V.H., Watts G.F., Thompson P.D. Optimizing cholesterol treatment in patients with muscle complaints. J Am Coll Cardiol, 2017, vol. 70, no. 10, pp. 1290–1301. doi: 10.1016/j.jacc.2017.07.752.
17. Mach F., Baigent C., Catapano A.L., Koskinas K.C., Casula M., Badimon L., Chapman M.J., De Backer G.G., Delgado V., Ference B.A., Graham I.M., Halliday A., Landmesser U., Mihaylova B., Pedersen T.R., Riccardi G., Richter D.J., Sabatine M.S., Taskinen M.R., Tokgozoglu L., Wiklund O. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J, 2019, vol. 31, pii: ehz455. doi: doi: 10.1093/eurheartj/ehz455.
18. Lloyd-Jones D.M., Morris P.B., Ballantyne C.M., Birtcher K.K., Daly D.D.Jr, De Palma S.M., Minissian M.B., Orringer C.E., Smith S.C.Jr. 2017 focused update of the 2016 ACC expert consensus decision pathway on the role of non-statin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol, 2017, vol. 70, pp. 1785–1822. doi: 10.1016/j.jacc.2016.03.519
19. Cosentino, F., Grant, P. J., Aboyans, V., Bailey, C. J., Ceriello, A., Delgado, V., & Huikuri, H. V. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASDThe Task Force for diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD). Eur Heart J, 2019, vol. 31, pii: ehz486. doi: 10.1093/eurheartj/ehz486.
20. Piepoli M.F., Hoes A.W., Agewall S., Albus C., Brotons C., Catapano A.L., Cooney M.T., Corra U., Cosyns B., Deaton C., Graham I., Hall M.S., Hobbs F.D.R., Lochen M.L., Lollgen H., Marques-Vidal P., Perk J., Prescott E., Redon J., Richter D.J., Sattar N., Smulders Y., Tiberi M., van der Worp H.B., van Dis I., Verschuren W.M.M., Binno S. ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Develope d with the spe cial contribution of the European A ssociation for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J, 2016, vol. 37, no. 29, pp. 2315–2381. doi: 10.1093/eurheartj/ehw106
21. Bangalore S., Fakheri R., Wandel S., Toklu B., Wandel J., Messerli F.H. Renin angiotensin system inhibitors for patients with stable coronary artery disease without heart failure: systematic review and meta-analysis of randomized trials. BMJ, 2017, vol. 19, pp. 356. doi: 10.1136/bmj.j4.
22. Fox KM, Mulcahy D, Findlay I, Ford I, Dargie HJ. The Total Ischaemic BurdenEuropean Trial (TIBET). Effects of atenolol, nifedipine SR and their combination on the exercise test and the total ischaemic burden in 608 patients with stable angina. The TIBET Study Group. Eur Heart J, 1996, vol. 17, no. 1, pp 96–103. doi: 10.1093/oxfordjournals. eurheartj.a014699.
23. Shu de F., Dong B.R., Lin X.F., Wu T.X., Liu G.J. Long-term beta blockers for stable angina: systematic review and meta-analysis. Eur J Prev Cardiol, 2012, vol. 19, no. 3, pp. 33–341. doi: 10.1177/1741826711409325.
24. Wallace W.A., Wellington K.L., Chess M.A., Liang C.S. Comparison of nifedipine gastrointestinal therapeutic system and atenolol on antianginal efficacies and exercise hemodynamic responses in stable angina pectoris. Am J Cardiol, 1994, vol. 73, pp. 23–28. doi: 10.1016/0002-9149(94)90721-8.
25. Kawanishi D.T., Reid C.L., Morrison E.C., Rahimtoola S.H. Response of angina and ischemia to long-term treatment in patients with chronic stable angina: a double-blind randomized individualized dosing trial of nifedipine, propranolol and their combination. J Am Coll Cardiol, 1992, vol. 19, pp. 409–417. doi: 10.1016/0735-1097(92)90499-D.
26. Hwang D., Lee J.M., Kim H.K., Choi K.H., Rhee T.M., Park J., Park T.K., Yang J.H., Song Y.B., Choi J.H., Hahn J.Y., Choi S.H., Koo B.K., Kim Y.J., Chae S.C., Cho M.C., Kim C.J., Gwon H.C., Jeong M.H., Kim H.S. Prognostic impact of betablocker dose after acute myocardial infarc tion. Circ J, 2019, vol. 83, pp. 410 –417. doi: 10.1016/j. jacc.2017.12.028.
27. Bangalore S., Steg G., Deedwania P., Crowley K., Eagle K.A., Goto S., Ohman E.M., Cannon C.P., Smith S.C., Zeymer U., Hoffman E.B., Messerli F.H., Bhatt D.L. b-Blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. JAMA, 2012, vol. 308, no. 13, pp. 1340–1349. doi: 10.1001/jama.2012.12559.
28. Motivala A.A., Parikh V., Roe M., Dai D., Abbott J.D., Prasad A., Mukherjee D. Predictors, trends, and outcomes (among older patients ≥ 65 years of age) associated with beta-blocker use in patients with stable angina undergoing elective percutaneous coronary intervention: insights From the NCDR registry. JACC Cardiovasc Interv, 2016, vol. 9, no. 16, pp. 1639–1648. doi: 10.1016/j.jcin.2016.05.048.
29. Dahl Aarvik M., Sandven I., Dondo T.B., Gale C.P., Ruddox V., Munkhaugen J., Atar D., Otterstad J.E.. Effect of oral beta-blocker treatment on mortality in contemporary post-myocardial infarction patients: a systematic review and meta-analysis. Eur Heart J Cardiovasc Pharmacother, 2019, vol. 5, no. 1, pp. 12–20. doi: 10.1093/ehjcvp/pvy034.
30. Puymirat E., Riant E., Aissaoui N., Soria A., Ducrocq G., Coste P., Cottin Y., Aupetit J.F., Bonnefoy E., Blanchard D., Cattan S., Steg G., Schiele F., Ferrie`res J., Juillie`re Y., Simon T., Danchin N. B blockers and mortality after myocardial infarction in patients without heart failure: multicentre prospective cohort study. BMJ, 2016, vol. 354, pp. i4801. doi: 10.1136/bmj.i4801.
31. Sorbets E., Steg P.G., Young R., Danchin N., Greenlaw N., Ford I., Tendera M., Ferrari R., Merkely B., Parkhomenko A., Reid C., Tardif J.C., Fox K.M. b-blockers, calcium antagonists, and mortality in stable coronary artery disease: an international cohort study. Eur Heart J, 2018, vol. 40, pp. 1399–1407. doi: 10.1093/eurheartj/ehy811.
32. Zhang H., Yuan X., Zhang H., Chen S., Zhao Y., Hua K., Rao C., Wang W., Sun H., Hu S., Zheng Z. Efficacy of long-term beta-blocker therapy for secondary prevention of long-term outcomes after coronary artery bypass grafting surgery. Circulation, 2015, vol. 131, pp. 2194–2201. doi: 10.1161/CIRCULATIONAHA.114.014209.
33. Rousan T.A., Mathew S.T., Thadani U. Drug therapy for stable angina pectoris. Drugs, 2017, vol. 77, pp. 265-284. doi: 10.1007/s40265-017-0691-7.
34. Heidenreich P.A., McDonald K.M., Hastie T., Fadel B., Hagan V., Lee B.K., Hlatky M.A. Meta-analysis of trials comparing beta-blockers, calcium antagonists and nitrates for stable angina. JAMA, 1999, vol. 281, pp. 1927–1936. doi: 10.1097/00132586-200004000-00039.
35. Ruzyllo W., Tendera M., Ford I., Fox K.M. Antianginal ef ficacy and safety of ivabradine compared with amlodipine in patients with stable effort angina pectoris: a 3-month randomised, double-blind, multicentre, noninferiority trial. Drugs, 2007, vol. 67, pp. 393–405. doi: 10.2165/00003495-200767030-00005.
36. Tardif J.C., Ford I., Tendera M., Bourassa M.G, Fox K. Ef ficacy of ivabradine, a new selective I(f ) inhibitor, compared with atenolol in patients with chronic stable angina. Eur Heart J, 2005, vol. 26, pp. 2529–2536. doi: 10.1093/eurheartj/ehi586.
37. Tardif J.C., Ponikowski P., Kahan T. Efficacy of the I(f) current inhibitor ivabradine in patients with chronic stable angina receiving beta-blocker therapy: a 4-month, randomized, placebo-controlled trial. Eur Heart J, 2009, vol. 30, pp. 540–548. doi: 10.1016/S0140-6736(02)08265-X.
38. IONA Study Group. Effect of nicorandil on coronary events in patients with stable angina: the Impact Of Nicorandil in Angina (IONA) randomised trial. Lancet, 2002, vol. 359, pp. 1269–1275. doi: 10.1016/S0140-6736(02)08265-X.
39. Morrow D.A., Scirica B.M., Karwatowska-Prokopczuk E., Murphy S.A., Budaj A., Varshavsky S., Wolff A.A., Skene A., McCabe C.H., Braunwald E. Effects of ranolazine on recurrent cardiovascular events in patients with non-ST-elevation acute coronary syndromes: the MERLIN-TIMI 36 randomized trial. JAMA, 2007, vol. 297, pp. 1775–1783. doi: 10.1001/jama.297.16.1775.
40. Kosiborod M., Arnold S.V., Spertus J.A., McGuire D.K., Li Y., Yue P., Ben-Yehuda O., Katz A., Jones P.G., Olmsted A., Belardinelli L., Chaitman B.R. Evaluation of ranolazine in patients with type 2 diabetes mellitus and chronic stable angina: results from the TERISA randomized clinical trial (Type 2 Diabetes Evaluation of Ranolazine in Subjects With Chronic Stable Angina). J Am Coll Cardiol, 2013, vol. 61, pp.2038–2045. doi: 10.1016/j.jacc.2013.02.011.
41. Weisz G., Genereux P., Iniguez A., Zurakowski A., Shechter M., Alexander K.P., Dressler O., Osmukhina A., James S., Ohman E.M., Ben-Yehuda O., Farzaneh-Far R., Stone G.W. Ranolazine in patients with incomplete revascularisation af ter percutaneous coronary intervention (RIVER-PCI): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet, 2016, vol. 387, pp. 136–145. doi: 10.1016/S0140-6736(15)00459-6.
42. Peng S., Zhao M., Wan J., Fang Q., Fang D., Li K. The efficacy of trimetazidine on stable angina pectoris: a meta-analysis of randomized clinical trials. Int J Cardiol, 2014, vol. 177, pp. 780–785. doi: 10.1016/j.ijcard.2014.10.149.
43. Noman A., Ang D.S., Ogston S., Lang C.C., Struthers A.D. Effect of high-dose allopurinol on exercise in patients with chronic stable angina: a randomised, placebo controlled crossover trial. Lancet, 2010, vol. 375, pp. 2161–2167. doi: 10.1016/S0140-6736(10)60391-1.
44. Singh J.A., Yu S. Allopurinol reduces the risk of myocardial infarction (MI) in the elderly: a study of Medicare claims. Arthritis Res Ther, 2016, vol. 18, pp. 209. doi: 10.1186/s13075-016-1111-1.
45. Ambrosio G., Mugelli A., Lopez-Sendón J., Tamargo J., Camm J. Management of stable angina: A commentary on the European Society of Cardiology guidelines. Eur J Prev Cardiol. 2016, vol. 23, no. 13, pp. 1401–1412. doi: 10.1177/2047487316648475.
46. Verma S., McMurray J.J.V., Cherney D.Z.I. The metabolodiuretic promise of sodium-dependent glucose cotransporter 2 inhibition: the search for the sweetspot in heart failure. JAMA Cardiol, 2017, vol. 2, pp. 939-940. doi: 10.1001/jamacardio.2017.1891.
47. Catapano A.L., Graham I., De Backer G., Wiklund O., Chapman M.J., Drexel H., Hoes A.W., Jennings C.S., Landmesser U., Pedersen T.R., Reiner Z., Riccardi G., Taskinen M.R., Tokgozoglu L., Verschuren W.M.M., Vlachopoulos C., Wood D.A., Zamorano J.L., Cooney M.T. 2016 ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J, 2016, vol. 37, pp. 2999–3058. doi: 10.1093/eurheartj/ehz455.
File extension: pdf (8.38 MB)